DERM: Acne, Rosacea, Urticaria, Drug Skin Reactions

ACNE

due to increased andorgen and sebaceous gland activity

types of acne

• non-onflammatory comedonal acne

  • open comedones (blackheads)

  • closed comedones (whiteheads)

• inflammatory (papulopustular) acne

treatment principles

• treated as chronic disease

• target all 4 mechansims of acne development

• maintanence therapy and lifestyle modifications

non-pharm recommendations

• balanced healthy diet

• stress control

• wash affected area no more than 2x daily w/ non-fragranced glycerin soaps or soapless cleanser

• avoid heavy scrubbing

• use gentle cleansers, sunscreen, sun protectants

• use non-comedogenic make up products

• cleanser after workouts

• use oil free, water-based moisturizers

• avoid scratching, picking, popping lesions

mild - mod non-inflammatory (comedonal) acne treatment

• goal

• 1st line

• 2nd line/alternative

• goal

  • decrease keratinocyte and sebum blockage

• 1st line

  • topical retinoids

    • adapalene (highest efficacy), tazarotene, tretinoin

    • benzoyl peroxide

    • combo: topical + benzoyl = more effective

• 2nd line/alternative

  • azelaic acid

topical retinoids

• MOA
  ADR

• precautions

• MOA

  • comedlytic

  • anti-inflammation

  • synergisitic w/ topical antibiotics

• ADR

  • skin dryness, photosensitvity

  • skin discoloration, swelling, blistering

• precautions

  • increased skin toxicity, sun sensitivity, skin erosion

  • fetal harm risk

Benzoyl peroxide

• MOA

• ADR

• precautions

• MOA

  • keratolytic

  • antibacterial

  • improve inflammatory and non-inflammatory lesions

• ADR

  • dry skin

• precautions

  • bleaching

  • skin peeling

  • safe in pregnancy

azelaic acid

• MOA

• ADR

• precautions

• pregnancy

• MOA

  • activity against all 4 pathogenic mechanisms of acne

  • keratinization, anti-inflammatory, anti-bacterial

• ADR

  • burning, pruritus, stinging

• precautions

  • hypopigmentation

• pregnancy

  • safe

• less effective than other 1st lines

T or F: combo topical retinoids, benzoyl peroxide, azelaic acid is okay

True

Mild-mod inflammatory (papulopustular) acne treatment

• goal

• 1st line

• alternative

• widespread disease

• goal

  • reduction of C. acnes colonization

• 1st line

  • adapalene + benzoyl peroxide

  • topical clindamycin + benzoyl peroxide

• alternative

  • different topical retinoid w/ other antimicrobial agent (Dapsone, Erythromycin) w/ or w/o benzoyl peroxide

• widespread disease

  • combo of sysyemic antibiotic w/ benzoyl peroxide OR

  • combo of systemic antibiotic w/ fixed dose combo of benzoyl peroxide + adapalene

topical antibacterials: Clindamycin, Erythromycin

• MOA

• notes

• MOA

  • reduce C. acnes

• notes

  • increasingly less effective due to resistance

  • addition of benzoyl peroxide or topical retinoids more effective than monotherapy

topical antibacterial agent: Dapsone 5% topical gel

• MOA

• use

• ADR

• MOA

  • synthetic sulfone w/ anti-inflammatory and anti-bacterial

• use

  • okay in pts w/ sulfonamide allerfy

  • improve inflammatory and non-inflammatory acne

  • increased efficacy in females

• ADR

  • dry skin, erythema, peeling

T or F: antibacterial agents should be used alone

False, do not use these alone

clindamycin + tretinoin (alternative agent) ADR

increased risk of sunburn

systemic antibiotics

• type of antibiotic

• agents

• MOA

• type of antibiotic

  • tetracycline

• agents

  • minocycline

  • doxycycline

• MOA

  • reduce C acnes

side effects

• minocycline

• doxycycline

• minocycline

  • photosensitivity

• doxycycline

  • photosensitivty

  • avoid isotretinoin use concomitantly

severe inflammatory (papulopustular, nodular, cystic) acne treatment

• 1st line

• 2nd line

• alternative therapies

• 1st line

  • oral isotretinoin monotherapy

• 2nd line

  • alternative ststemic antibiotics +

    • fixed dose adapalene-benozoyl peroxide combo OR

    • adapalene-azelaic acid combo

• alternative therapies

  • anti-androgen in combo w/ oral antibiotics

  • topical treatments

  • systemic antibiotics in combo w/ benzoyl peroxide

oral isotretinoin

• MOA

• goal dose

• SEs

• precautions

• CI

• BBW

• MOA

  • synthetic analog of Vitamin A

  • inhibit sebaceous gland function and keratinazation

  • reduce inflammation

• goal dose

  • cumulative dose of 120 mg/kg over 4 - 6 months

• SEs

  • photosensitivity, anemia, increased LFTs

  • thrombosis, neutropenia, thrombocytopenia, neuritis, depression, psych disorders

• precautions

  • avoid use of tetracycline, vit A supplements, John worts

  • risk of scarring up to 6 months

• CI

  • pregnancy

• BBW

  • pregnancy X

  • high risk of birth defects

iPLEDGE REMS program

• goal

• who must be registered/activated

• to prevent fetal exposure

• prescribers, pharmacies, patients

other treatmenrs for hormonal acne (for females)

• antiandrogen compounds

  • oral contraceptives (estrogen/progesterone)

  • spironolactone

• light therapies

oral contraceptives (estrogen/progesterone)

• beneficial if acne is menstrual or ovarian disease-related

• may be superior to oral antibiotics for long term maintenance

spironolactone

• MOA

• SEs

• precautions

• MOA

  • antihypertensive

  • interferes w/ testosterone biosynthesis

• SEs

  • gynecomastia

  • erectile dysfunction

  • hyperkalemia

T or F: hormone therapy (spironolactone + OC) should not be combined with each other

true, however sprinolactone can be combined with systemic antibiotics and topicals

T or F: light therapies are a weak recommendation

true

Maintenance therapy

• 1st line

• alternative

• other

• 1st line

  • topical retinoids

• alternative

  • azelaic acid

• other

  • continue hormonal therapy if it works

  • long term therapy w/ oral antibiotics NOT recommended

  • 2nd course of isotretinoin

URTICARIA (HIVES)

due to allergic reactions

type 1 immediate hypersensitivity (IgE-mediated)

urticarial rash

treatment of new onset urticaria

• often self-limiting

• 1st gen AH

• 2nd gen AH

• systemic glucocorticoids

1st gen AH

• agents

• MOA

• ADR

• precautions

• agents

  • diphenhydramine

  • chlorpheniramine

  • hydroxyzine

• MOA

  • lipophilic

• ADR

  • sedation

  • dizziness

  • xerostomia

  • anti-SLUD

• precautions

2nd gen AH

• agents

• advantages

• agents

  • cetirizine

  • loratidine

  • fexofenadine

• advantages

  • safer in older adults, no sedation

is it okay to take 1st and 2nd gen AH

yes, if separated

systemic glucocorticoid (Prednisone or equivalent)

• not necessary for isolated urticaria

• may be needed if angioedema present

• does not inhibit mast cell degranulation, but suppress inflammatory mechanisms

when to refer / emergency attention

• suspiciion of anaphylactic reaction

  • difficulity breathing

  • throat closure

  • wide-spread and worsening sxs

  • severe angioedema

  • angioedema in face

• prescribe epi for self-injection

ROSACEA clinical features

• due to abnormalities in innate immunity

  • centrofacial erythema

  • papules, pustules

  • flushing

  • spider veins (telangiectasias)

  • burning, stinging

  • edema

  • dry skin

  • ocular involvement

exacerbating factors of rosacea

• temp changes

• sun exposure

• alcohol

• spicy foods

• skin irritants

• vasodilators

treatment of rosacea

• vascular features

• facial erythema

• papules and pustules

• vascular features

  • laser and intense pulse light

• facial erythema

  • vasoactive alpha 2 adrenergic receptor agonists

    • topical brimonidine

    • topical oxymetazoline

• papules and pustules

  • topical metronidazole

  • topical ivermectin

  • topical azelaic acid

DRUG INDUCED SKIN RXNS

• epidemiology

• pathophysiology

• epidemiology

  • prevalent in women and elderly pts

• pathophysiology (non-immuno mediated)

  • accumulation and direct release of mast cell mediators: dose dependent (ASA, NSAIDs, hydralazine, vanco, opiates)

  • intolerance: due to altered metabolism

  • Jarisch-Herxheimer phenomenon: result of bacterial endotoxins/microbial antigens released by microorganism destruction

  • overdosage or phototoxic dermatitis

classifications of ADE

• type A

• type B

• type A

  • associated w/ therapeutic dosafes

  • predictable and avoidable

• type B

  • independent of dose

  • rarely predictable or avoidable

  • uncommon but serious and life-threatening

types of immuno-mediated (type B) reactions

• type 1

• type 2

• type 3

• type 4

• type 1

  • immediate hypersensitivity

  • IgE, mast cells

• type 2

  • cytotoxic

  • IgE mediated

  • hemolysis, thrombocytopenia, purpura

• type 3

  • immune-complex

  • IgG-drug complex

  • vasculitis, serum sickness, urticaria

• type 4

  • delayed

  • contact dermatitis, exanthematous rxns, photoallergic rxns

acute types of drug-induced skin rns and causative agents

• erythematous multiforme/morbilliform eruptions

  • type 4

  • starts at trunk, extends to extremeties

  • spares face, palms, soles, mucous membranes

  • PCNs, cephalosporins, sulfonamides, anticonvulsants, allopurinol

• urticaria, angioedema, anaphylaxis

  • NSAIDs, vanco, ACEis, chemo, opiates

• hypersensitivity syndrome (DRESS)

  • fever, exanthem, internal organ invovled

  • lead to dermatitis, facial edema, etc

  • allopurinol, sulfonamides, anticonvulsants, vanco, dapsone, minocylcine

• SJS and TEN

  • life threatening

  • SJS: < 10% BSA

  • SJS-TEN: 10 - 30% BSA

  • TEN: > 30%

  • high risk for infection and sepsis

  • allopurinol, sulfonamides, anticonvulsants

• warfarin-induced

• serum sickness like rxns

  • cefaclor, minocycline, PCNs

• photosensitivtity

  • FQs, amiodarone, MTX, furosemide, TCNs, sulfonamides, thiazides, sulfonylureas, ACEis, CCBs

HLA-B1502 allele

• high risk for CBZ-induced SJS/TEN

• high prevalence in asian population

HLB5801 allele

• high risk for allopurinol induced hypersensitivity syndorme (SCARs)

• common in asian populations

T or F: do not rechallenge w/ drugs causing urticaria, bullae, angioedema, DRESS< anaphylaxis, erythema multiforme

true

chronic types of drug induced skin reactions

• drug-induced lupus

  • associated w/ Hydralazine, Procainamide, Quinidine, Isoniazid, Methyldopa, Minocycline

  • drug induced ance

    • different from acne vulgaris by absence of gross and/or microscopic comedones

    • associtated w/ corticosteroifs, androgenic hormones, lithium, isonizad, azathioprine, EGFR inhibitors

    • use topical acne treatments to manage

corticosteroid ADR: glucocortico

• glacuoma

• lunacy (mood swings)

• ulceration

• cushings

• osteoporosis

• cataracts

• opportunistic infections

• retention of Na

• telangiectasia

• insulin resistance (hyperglycemia)

• causes of muscle weakness

• growth retarfation